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HomeMy WebLinkAbout1269A WORTCERS'CO�iPEIrSATION DECLARATION 76A663� ' � �" ---�• �-^'""� �E_8o6��z-so, APi�LICp►T�IbN�� FC��'�ELI��T'�I��`CAL ��`RIG(��" �,`� .�.�.,.�. �_... _� :. . . . , IJ. I hereby affirm ihat I ha�e a certificate of con9ent to self COUNTY OF LOS 7iNC`',E�LES` ` " B[71L�DING ANd SA�TIY y � insure,or a certificate of Workers'Compeniation Insurance,ot � � , a certifieQ copy thereof(Sec.3800,Lab C j � ' � �. . . . ' . . ... ,. _ ,, � a" fv,p'!�p`f�'� �Y�.r.,��yC��� FORAPPLICANTTOFILLIN . �pg . Policy No. ompany N EACH No. FeE �2 `�T�'PL'�'�� ��- '-� ��. �� ,�,����� - 'r- .' . .... � ���� � � New Residential Bldgs.&Pools aooRess '�33 Certil'ied copy is hereb5 furnished. 1&2-Family,Sq.Ft. S — � LOCALI7Y ���"��j�J ��,(7 �CertiFied copy is fited with the county buildin Multi-family Sq.Fi. — NEAREST g inspection CROSS ST departmenc. y Residential Swimming PoolS OWNER OR Date l�✓�'�9 p liCantJ/��� FIRM NAM� ��✓.L�/mi�.,(� �',z�,�r.�,I"DN Pp Outiets:Rec.,_Liaht .—Fjsst 20 � ADDRESS �.�.Y�� S//.�jQU1i7 �CERTII'ICA"CE OF CX�bfPTION FROM WORKF.RS' Total No. Addltional CITv �,I+����j���r Tel No,��y��j�f'2 COR§PENSATIOV IFISURANCF. PLAN CHECK ' � a (This sectlon�need��not be completed�if�the�work involved� � ' APPLICANT Q by the permit is for one hundred Qollaxs.($100) or IessJ Lighting Fixtures First 2Q qpDRESS � � � Total No. A�ditional � I certify that in tfie performsnce of the�Jork�for��ahich this Fixed Appliances Not Over 1 HP CITY � Tel No. � permit is issued,i shall.n�[employ any person in any manner PERMIT � so as to become subjecf to the R'oikers'Compensa[ion La�vs. Range_Heater_D;W. APPLICANT c�d�.��/0`r���; �✓�l� W � ' , ' � � - Over. _�ryer_W.M. ADDRESS S�p� S•z�dST�iPit7 .ddf�✓'/,� � Date Applicant ' Top _FqU _W.H.._ _ � � � � Hood—Fan _Other_ CITV C-p)y, �ten�-�' re�No.7�y��33�.,2 NOTICL 7'O APPLIC.KNT:Ii,�after�maAing this Cer4ifi'cate of Disp. _Room Air Cond` LICENSE OR Exemption, you�Sliould become��subject to the�-Workers' REG.�NUMBER -���'��J� Class .f'C� Compensation proiision5 of the Labor�Code,you must forth- power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY w�ith comply wi[h such provisions or [his permit shall Ne deem=d revoked. - � Size&Type HP,KW,KVA,6r KVAR . � Up to 1 Incl, -i F' ' f�' CGbcP� � OVer 1 to 10 Incl. FINAL � ' LICENSED CONTRACTORS DECL;ARATION � DATE c�_t��Ci VALIDATION . . . . �. � Over 10 to 50 Incl. �� O 1 hereb}•uffirm that I am':icensed under�provisions of Chapter Over 50 to 100 Inc. FINAL BY -__'� 9 (commencing witti�Section 7000)of�nivision"3 of the�Busi- Over 700 ness und Yrofessions Code,and my�l'icenSe'is�id'fuffforce and� effect.� ' g Services License Number�� !`��Y/ Lia Class ��� 0-200 Amp,Under 600 V 207-1000 Amp.Under 600 V Contrector��+��'�'�Ol-" Date-�J'etT�� Over 1000 Anip.or Over 600 V H031E 6lVNER�BUILDER 6CCtKR:ATiON '�- � - -� Temp.Power Pole&Appurtenances Sign with One Branch Circuii I hereby affirm that I am exempt from the ConUactor's Additiona�Sign Branch Circuits LicenSe La�s for[he�following�,reason�(Seetiop''703Y.5, Busi- ness and Professions Code): Misa Conduits&Conductors �� r�.9 A � I, as owner ot the property,will do the u�ork and the Other(See Complete Fee Schedulel— s[ructure is not intended or��offece'd�-for s21�e�(Section� �m e � a o 2 7044,Business and�Professions Code). � CONSTRCICTION 18N�[VG�1GHNCY [ hereby�affirm that tliere is a construction lending agency � ° m 1 1.5 0 for the�performance of the work�for��ehich [his permi[ is pERMIT FEE (Sub-Total� � issued(Sec.3091,Civ.C.). ° � e � �.5�i� [.ender's Name � . � PLAN CHECKING FEE (One-Fourth.Permit Fee1 �+ i (�_,�2 Lender's Address . PERMIT ISSUING FEE j� `) ' i certify that I hace rzad�this'applicati'o'n'and sta'te tha[tfie� � TOTAL FEE �� S'�j a6ove inforrciation is cortect.1�gree to comply ioith all Coiirity � rndinances and'State�iaw�s iegulating�E�leetrical�iviring.�and � � � � � - � � � � � � � ' - � hereby authorize representatives of ttiis Courity to enter upon � ' ' �� � " � � ' � the above-mentioned property�for inspection purposes. �� � � � - .. ,,,,�,�;,, ,,,_ _.-,_,,,.-., .,._...,._.. ..... ..... . . . . . . . . � � ✓��-. � SEE'REVERSP FOR'EXPLANATOR4�I;AN(;UAGE'�"-� - � � , „ ��.��� !f%�.er� ' . Signature of Permit[e- , . Dnte, . , ' �' ' • : l;bro'?4�R-�[1:Le)EI�.E4Ew'LAR.�T?�i!` ' . � S 3iaxeby aCfiim.tl�af.:ac7 exempt fram the Cc�r,taactoe's . . .. . .. qFp,R�VR_c . oArE ��•��'ECTCP�s-? . :-2exr,se,S_1`,Y.�:+�t,d;e ioi?o:c�ing�rea;er/Sec:idrc�?G.f7.5, . - . ` . . _.__T_ __'__ SIGNATURE._j � SC!StHeS.S�dnd�Pt'Ofe5.TiG�2� COCIeI: .A3ty crd� nr'co�en.�y -�EYTetviP PO!hER POL� , I � ' I � - n%h:ch requires a permrr 1u c�r:stn�ct. 21?2r, %»�prove, ',' , "_'__ .i. _.___��_, _ ._. ._ . � - `UNDERSLAB WOSiK �— � � `�P ')iiSY 13Y 7@p4lr[lity s��k�etttre,pr%or ti tS iSs'.'!!t?Ce, � � ' ' � ulao reraurrea `he .ppticun: Jvr such perm f tc fi�e a `ROt U H CO�DU1T � �- -� � - �� � � �� . � stgned sia err=nr lr�aF :+e is :rcznsed pursua tt�.n�tfae . F_'r_'__'_— pro isdotts oJ +.�e.Co�i!mctar's r°.ices+se LaA lChcnrer 9 . . p�VJIftING _ _ __ , _ - , . /,�rr.n:e:2cang�w•a?n Ser.t�on 7v"�:3;�of Dr•:isiert 3 of 1k2 � � �FIxTUr�ES: � - � • . ' .�',usiness and Prcf2.xsi�ria E'odeJ or lhat hz !3•exempt � � - �� � � � tnere,ror�s ar.d th.e:iasis fvr tne alCtyed eserrption.Any - Ro'vvE�Au7r,^oRizso � � .. ._ . . . . . . . s�ivlatiano;5eci�.n iC'3:1:S�bYanYGpR=izarrrjarapermit -- UTILITv CO.No71F.IF_e�� - � ��� � � stlbj2cts tYe¢p77i.^ant to a civil penvL,'y oj n.at more tf«7 � � . . _� � . .., ,._.__� -. , ... .. ; �f�yg.¢JI?*4i l�llOiiUFc(wJ�.�'i�.. l . . �FINA�� . . ��2.�e2.�t'rr�st� : ' � L�. I ac o�cnc*of tlm Q.o�erty u�.l do the��o:k,artd � ' ' £he sf�i�sczu.-e is no[mter.ded o�offeeed t'oi aale. ' h10TES . —'—'_-- ...� �... .� . /.52c. 7G4�F. Bu.rircea�Gnu Profr.c:i�ns C�de: .T'hs�:ot,�. _ ,. � . � trector's e_ac�rse.Law deen:noi ap�i,� IO(l.'t'OK'iiCf pf . . -----.�_�,.�_.�..�.�..... . -- � .�rcPe�Y x•P:o bae;iJ,s t�:improves:hereor,a;��d w;o does � .. . . , . ..; ......................._,.. ._ ' . . . . .. .. � .. . .. . .. � r:�c'rr u ork himaeij Gra�lded Cr�at such i�;xprov�mzn�c �� .._.....___..� ..�,— ------.._.,_.�.�, -------....are not ir-rended er oP.�red for��atz. Tf, howerer, tMe _ . . ... ... _. .... , . . . ._....,---.... . . .._ .. . . - � .. . , ' . bu:73.ra� ar irnprUve�ner.t is sr�td :v.irhira or.e,year pj —._�____ �_�.__..__'�._—_._.__.._._._.,.._...__,._.._.___._ r,nmpie%?on,; zire�own.er-{Suii�inr svill isqvn eh.e.burden - ' - . ' ' ' , - �- . . of pr,^,vinn thnt�lse�d%cl ;mz Suild or i3nprote;pr t.he . .. . ---, .�.. .nsrpo;e c;sr,ie.,' � . . ' " �- � '--.� —........._�...._.�.��_�W_..�_�._..---'----'-'- ' +a+r e.iem�e inoer Ser....._._ __.___. -- � --------- ------- i3 r3 a.C.£ar titis reasan� � 3Bate._.Y�—.:....�..------ ,,. . .. . . ..... ._... _._._._....�._........----------__.._____,.,..,_..,.._.. ?Pxmee _. ,. '. ,, r ,